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  • Writer's pictureEscuela de alopecia

One Single Large Hair Transplant or Multiple Surgeries?

Today, we're going to talk about a frequently asked question in my practice: How many transplants do I need to improve? One Single Large Hair Transplant or Multiple Surgeries?


The issue with transplantation lies in the donor area. We utilize a limited resource, which is the number of hairs we have to donate and place in the area where it's most needed. Furthermore, the problem is that the balder you are, usually your donor area, where we take the hairs, is smaller. So, there's sometimes a mismatch between people who need a lot of transplants but have little to donate, and vice versa.


Let's try to simplify this a bit. I'll try to draw a parallel with cartridges. Let's say a person with a good donor area has three cartridges, three surgeries. Each cartridge, let's say, contains about 2500 follicular units. Thus, one cartridge is 2500, two cartridges are 5000, and three cartridges are 7500 follicular units available for donation.


cartuchos alopecia

To donate without negatively impacting the donor area's image, you know that what we usually do is extract the hairs uniformly, distributing this extraction by quadrants throughout the donor area but in a uniform manner, avoiding areas that may be more worked on than others so as not to attract too much attention.


Obviously, there is no magic, and if the patient shaves, marks will be noticeable, but generally, a patient whose hair is not shaved much, it's normal not to be noticeable. Especially, a normal person has two to three cartridges. A person with a good donor area has one to two cartridges, so the cartridges need to be used very well, okay. In fact, it generally tends to be a bit more tedious when it comes to second or third transplants.


A few days ago, this patient came for a review, whom I transplanted about a year ago, and it was the idea to make this video to convey a bit about my perspective on doing a single transplant in patients who probably need more transplants. Because this patient had a large transplant, about 3700 units approximately, for the entire recipient area, but with some conditions, that's what I want to convey for you to understand.


resultado trasplante

We are going to divide the recipient area. Usually, as you know, it will be the frontal zone, one-third forward, one-third anterior, the interparental zone, which is the middle area, and the crown zone. In my humble opinion, though this is debated, but in my humble opinion, priority is given to the front, then the crown, and the last priority is in the middle.


Years ago, I thought differently, but now I think like this. You can see a bit of the correlation that there are three zones and there are like three cartridges, okay. So, in the case of wanting maximum density everywhere, you will have to use all the cartridges, do several surgeries. But this is not always possible. Obviously, if we do more surgeries, we can do more, cover more, more coverage, but also, obviously, more economic impact for the patient and more postoperative because it is spread over more surgeries.


That's why many patients ask you, or maybe they have the idea, 'doctor, can I try to do just one surgery?' The main current limitation of the transplant technique, as of today, in the year 2024, and it doesn't seem to change in the coming years, is that the time your hair spends outside your body affects how well they survive later, in addition to other variables.


This means that even though years ago it became fashionable to do what are called mega-sessions, very large transplants in a single day, of more than 4,500 follicles, currently, attempts are made to do fewer. In fact, my usual limit is between 3,500 and 3,800, at most, in a single day of 8 to 9 hours.


Why? Because beyond that time, apart from the fact that, of course, for me and the team, it is very tiring, even if the patient is asleep, sedated, and I usually operate with an anesthetist, it can also affect the final result. If the hair spends too much time outside the body, that's why, perhaps, in your particular case, if of those three areas that I mentioned, you need to repair two, you may need two separate transplants because you need more than 5,000 follicular units to cover those areas.


The main advantages of doing a single, slightly more ambitious transplant are that it is less costly for the patient, the postoperative logistics are just once. And the main advantage is, you know, 'he who embraces much, squeezes little.' And this makes sense also in the transplant. If you spread the hair too much in all areas, you will give less overall coverage because they are less close. Although it may mean that you have to do another transplant later to fix it or improve it, it's not that serious.

Always let the patient know that this can happen. I mentioned before, this patient is a case that I consider a success in transplant strategy, and his hair loss is very significant. And it's one of those cases that probably, maybe, the textbook decision would have been to do at least two transplants, one in front and one behind. But I have achieved quite good coverage.


It is true that there are some areas that could possibly be better covered, like the area a little further back, but that's the price to pay for doing a single large transplant and saving the second transplant, which of course, the patient is delighted not to have to do his second transplant and is happy like that. What the patient saves, I explained to him two conditions, which are the ones I explain to patients when they want to do something like this.


The first condition, the front area. We will improve it, but we will not lower the first line too much. Notice how this patient, yes, yes, of course, has greatly improved the front area, much more opaque, very natural, and I like it a lot, as I like my lines. But I haven't lowered it much, why? Because if I lower it a lot, I will spend a lot of hair in front that I cannot use behind.


So, the first condition is, of course, you can do it, but I can't lower the first line too much. I will densify it, so it's much more opaque, but I won't lower it too much. Notice, on the left, I put the image of just finishing the transplant of this patient I told you about, this case, let's see how he left the operating room. Notice how I distributed the units, and on the right, I put the case from yesterday, a surgery in which I only transplanted the anterior third. There have been a little fewer follicles than the ones on the left, but it has practically come close, really close to about 3,000 units, to give ultra-density to the front area.


Notice that more or less the number of units is similar, with some lag, but a completely different strategy. Obviously, in the patient I just operated on yesterday, I expect a very brutal improvement in the entrances because I want to lower them, and I have to put together many units. But in this other example of the patient, which I think is a good example to illustrate more extended surgeries, I haven't lowered the front line.

And the second condition that I make clear, and in fact, on my website or on my phone, actually, I have the part of the photos on the computer and on the phone for the transplants. Let's see when I upload them when I have time. I show cases of crowns, what I think is a normal response. Because I do make it clear that with this more ambitious approach in extension, I prefer them to think that, although it will certainly improve the crown a lot, like this patient, I don't think it will completely cover the crown.


I want that to be clear. To completely cover the crown, a specific crown surgery is required, and sometimes, even so, it has to be touched up. I have told you many times that crowns are black holes. You put hair and hair in there, and it's hard for them to completely fill up to the last hair. But if the patient accepts that, even if it doesn't improve 100% of the crown, it improves 80%, and even if you don't lower the entrances much but gain a lot of density here. And maybe, with a single surgery, like this case, you achieve a global improvement of an 8 or so, I think it's an appropriate option to consider this more extensive approach.


This more extensive approach, in addition to condition number one, which is that you don't want to lower the first line too much, and condition number two, that you are not worried if the crown does not close completely, requires a condition on your part that does not depend on you, but on your donor area. And it is that I, at least, see that you have like one and a half cartridges, let's say, or almost two cartridges, to feel calm that this can be extracted.

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